Agent-specific differences in sustained intraoperative hypotension during oral 5-Aminolevulinic acid-guided transurethral resection of bladder tumor: A retrospective observational study

• Safe performance of oral 5-ALA–guided TURBT is essential to fully realize its benefit in reducing bladder cancer recurrence. • Sustained hypotension occurred in 25% of patients undergoing oral 5-ALA–guided TURBT. • Remimazolam anesthesia was associated with a lower risk of prolonged hypotension. • Appropriate anesthetic selection may enable wider and safer clinical use of oral 5-ALA. Severe intraoperative hypotension is frequently reported during transurethral resection of bladder tumor (TURBT) using orally administered 5-aminolevulinic acid hydrochloride (5-ALA); however, the influence of anesthetic technique on prolonged hypotensive episodes remains unclear. We retrospectively analyzed 423 consecutive patients who underwent oral 5-ALA-guided TURBT between 2018 and 2024. Sustained hypotension was defined as mean arterial pressure <65 mmHg lasting ≥30 min. Baseline characteristics, anesthetic variables, and hemodynamic parameters were compared between patients with and without sustained hypotension. Multivariable logistic regression was used to identify independent predictors. Among patients receiving general anesthesia (n=274), the incidence of sustained hypotension varied significantly depending on the anesthetic agent (p=0.02). In multivariable logistic regression, remimazolam was independently associated with a significantly lower risk of sustained hypotension compared with sevoflurane (adjusted OR 0.35, 95% CI 0.14–0.83, p=0.02). Approximately one-fourth of patients undergoing oral 5-ALA–guided TURBT experienced sustained intraoperative hypotension, with spinal anesthesia showing a lower incidence than general anesthesia. Longer anesthesia and surgical durations increased the risk. The choice of anesthetic agents under general anesthesia also appeared to affect the risk of sustained hypotension. These findings highlight the importance of individualized anesthetic management to maintain hemodynamic stability during this procedure.